Provider Demographics
NPI:1346429495
Name:APPLE GROVE TREATMENT CENTER
Entity type:Organization
Organization Name:APPLE GROVE TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:REID SANDULAK
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:702-369-0396
Mailing Address - Street 1:368 PLACER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-4557
Mailing Address - Country:US
Mailing Address - Phone:702-369-0396
Mailing Address - Fax:
Practice Address - Street 1:2060 WAVERLY CIR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-4593
Practice Address - Country:US
Practice Address - Phone:702-369-0396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV32-2D00000XMedicaid